Management of Cleft Palate in Puppies Using A Temporary Prosthesis: A Report of Three Cases - MDPI
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veterinary sciences Case Report Management of Cleft Palate in Puppies Using A Temporary Prosthesis: A Report of Three Cases Theresa Conze 1, *, Isabelle Ritz 2 , Rainer Hospes 1 and Axel Wehrend 1 1 Clinic for Obstetrics, Gynecology and Andrology of Large and Small Animals with Ambulatory Service, Faculty of Veterinary Medicine, Justus-Liebig-University, 35392 Giessen, Germany; rainer.hospes@vetmed.uni-giessen.de (R.H.); axel.wehrend@vetmed.uni-giessen.de (A.W.) 2 Department of Veterinary Clinical Science, Small Animal Clinic, Surgery, Justus-Liebig-University, 35392 Giessen, Germany; mail@isabelle.ritz.de * Correspondence: theresa.conze@vetmed.uni-giessen.de; Tel.: +49-641-9938-707 Received: 26 May 2018; Accepted: 20 June 2018; Published: 24 June 2018 Abstract: Cleft palate in dogs is a congenital defect that mostly leads to euthanasia of the affected puppy. If an attempt is made to raise the puppy, it is generally fed via an orogastric tube. Here, we describe the management of cleft palate in three puppies (two Boxers, one Collie) using a customised temporary prosthesis, which allowed the puppies to be bottle-fed and successfully raised by their owners (Cases 2 and 3) and the author (Case 1). The temporary palatal prosthesis was manufactured from a mouthguard intended for human children, which is made of thermoplastic silicone. The preparation procedure was simple and cost-effective. All puppies underwent corrective surgery at 5–6 months of age. After surgery, one of the Boxer puppies showed mandibular mesioclusion, while the other two showed no aberrations. All puppies gained the same amount of weight as their littermates, although the weight gain of the two Boxers was slower than that of their littermates. In summary, this case report describes an easy and effective way to raise puppies with cleft palate until corrective surgery can be performed. Keywords: cleft palate; palatoschisis; puppy; temporary prosthesis 1. Introduction Palatoschisis, also known as cleft palate (CP), is a craniofacial defect characterised by an abnormal communication between the oral and nasal cavities and is one of the most common craniofacial defects in dogs [1–3]. Because of this abnormal connection, suckling is impaired and the risk of aspiration pneumonia is high [4]. The only successful treatment for CP is corrective surgery, which is best performed once maxillofacial growth has slowed down or ceased completely [5]; Fiani et al. [5] recommend an age of about 4–6 months [5]. If corrective surgery is performed earlier than the recommended age, there is a high risk of dehiscence and maxillary growth delay [5]. However, raising puppies until the appropriate age for corrective surgery is challenging, and most puppies are euthanised because of the costs and intensive care required. Neonates that are raised until an age appropriate for surgery are mostly fed by an orogastric tube [6]. In the present report, we describe the successful management of CP using a customised temporary prosthesis in three puppies, and demonstrate an easy and affordable way to raise puppies with CP until corrective surgery can be performed. Vet. Sci. 2018, 5, 61; doi:10.3390/vetsci5030061 www.mdpi.com/journal/vetsci
Vet. Sci. Vet. Sci. 2018, 2018, 5, 5, 61 61 22 of of 77 2. Case Presentation 2. Case Presentation 2.1. Cases 2.1. Cases Case 1 involved a 3-day-old male Boxer puppy that presented at the Clinic for Obstetrics, Case 1 involved Gynecology a 3-day-old and Andrology of Large male andBoxer Smallpuppy Animalsthatwith presented at the Service Ambulatory Clinic for Obstetrics, of the Justus- Gynecology and Andrology of Large and Small Animals with Ambulatory Liebig University in Germany. The owner reported that the puppy was very active and continuously Service of the Justus-Liebig UniversityNonetheless, suckling. in Germany. he Thedid ownernot reported gain weight, that the andpuppy was very the owner active and frequently continuously observed suckling. nasal discharge Nonetheless, after suckling.he did not gain weight, and the owner frequently observed nasal discharge after suckling. On examination,thethe On examination, puppy puppy exhibited exhibited a good a good general general conditioncondition and wasand verywas very lively. lively. Intraoral Intraoral examination examination revealed CP revealed (FigureCP (Figure 1). The 1). characterised CP was The CP was characterised by a midline defectby a midline in the hard defect in palate the hard palate and a caudally divergent defect in the soft palate. and a caudally divergent defect in the soft palate. The defect was moderately wide, and no The defect was moderately wide, and no asymmetrical asymmetrical facial growth facial growth could be could be detected. detected. CP was CPclassified was classified as “- -asH“-S- HH -S-“ H according - -“ according to to the the LAHSAL LAHSAL classification classification [7]. [7]. No No other other congenital congenital diseases diseases were were detected, detected, andand the the puppypuppy showed showed no no signs of pneumonia. When milk replacer (Babydog Milk ® , Royal Canin, Köln, Germany) was signs of pneumonia. When milk replacer (Babydog Milk® , Royal Canin, Köln, Germany) was offered, offered, the puppy the suckled puppy suckled immediately. immediately. Although Although he showed he showed nasal nasal discharge discharge and and occasional occasional sneezing, sneezing, he he demonstrated a good appetite. He required a long time to consume the demonstrated a good appetite. He required a long time to consume the amount of milk necessary for amount of milk necessary for gaining gaining body body weight. weight. Because Because of his of good his good general general condition, condition, an attempt an attempt at raising at raising him himwas was made made and and the puppy was assigned the puppy was assigned to the clinic. to the clinic. Case 22 involved Case involvedaafemale femaleBoxer Boxerthat thatpresented presented with a congenital with a congenitalpalatal defect palatal on the defect onday theof birth. day of The puppy was diagnosed with cleft lip and palate (CLP), or cheilognathopalatoschisis, birth. The puppy was diagnosed with cleft lip and palate (CLP), or cheilognathopalatoschisis, which which was classified was as “- -asH“- classified SH -H A L” S Haccording A L” according to the LAHSAL classification, to the LAHSAL which is awhich classification, systemisfor classifying a system for clefts [7]. The defect was narrow in both the hard and soft palate, measuring classifying clefts [7]. The defect was narrow in both the hard and soft palate, measuring between between 1–2 mm in width. 1–2 No facial mm growth in width. Noabnormalities facial growthwere observed. The abnormalities were puppy showed observed. Thea normal birth weight, puppy showed was lively, a normal birth and showed no other deformities during examination. weight, was lively, and showed no other deformities during examination. Case 33involved Case involved a male Collie a male that presented Collie with mild that presented with bronchopneumonia, mild bronchopneumonia, which waswhichdiagnosedwas based on a based diagnosed clinicalonexamination, a complete ablood a clinical examination, count,blood complete and an ultrasound count, and an of the lungs.ofThis ultrasound the puppy lungs. presented This puppyatpresented the age ofat12the days. age The of 12puppy was puppy days. The found to was have founda continuous hard and soft to have a continuous hardpalate and defect, classified as “- - H S H - -“ according to the LAHSAL classification [7]. soft palate defect, classified as “- - H S H - -“ according to the LAHSAL classification [7]. The defect The defect was narrow, and narrow, was no facialand growth abnormalities no facial were seen. The growth abnormalities wereowners of both seen. The puppies owners of bothwere willing puppies to attempt were willing raising them. to attempt raising them. Figure 1. Cleft palate in a 3-day-old purebred male Boxer puppy (Case 1). Figure 1. Cleft palate in a 3-day-old purebred male Boxer puppy (Case 1). 2.2. Customisation of A Palatal Prosthesis A temporary prosthesis was crafted from a mouthguard intended for human children (Wilson Single Density Youth Mouthguard; Wilson, Chicago, IL, USA), which is made of thermoplastic silicone and can be reformed by heating in hot water. About 1–2 cm of the mouthguard was cut off
Vet. Sci. 2018, 5, 61 3 of 7 2.2. Customisation of A Palatal Prosthesis A 2018, Vet. Sci. temporary 5, 61 prosthesis was crafted from a mouthguard intended for human children 3 of 7 (Wilson Single Density Youth Mouthguard; Wilson, Chicago, IL, USA), which is made of thermoplastic (Figure 2a) silicone andand canplaced in a cup be reformed bywith boiling heating water. in hot After water. a few1–2 About seconds, cm of the material mouthguardsoftened wasand the cut off silicone2a) (Figure could and beplaced reformed in afor cupabout with30–60 seconds. boiling water.Thus, Aftera plate a fewwith a height seconds, theof approximately material softened 0.3and cm wassilicone the prepared. could During the crafting be reformed procedure, for about the mouthguard 30–60 seconds. Thus, a plate was heated with andofsoftened a height several approximately times. 0.3 cm wasAfterprepared. hardening, the edges During of the plate the crafting were cut procedure, the off until a sizewas mouthguard matching heated that and of the upper softened jaw several of the After times. puppy was obtained hardening, (Figure the edges 2b).plate of the When the cut were optimal sizea and off until size thickness matching that(approximately of the upper4jaw cm long, of the 2puppy cm wide, was 0.3 cm thick) obtained were (Figure achieved, 2b). When the theoptimal siliconesize plate andwas pressed(approximately thickness against the upper4 cmjawlong,of 2the cmpuppy wide, 0.3(Figure 2c) towere cm thick) produce a prosthesis achieved, the siliconethatplate was was adjusted pressedto against the maxilla (Figure the upper jaw2d). No of the anaesthesia puppy (Figurewas2c) required to produce during this procedure. a prosthesis The prosthesis that was adjusted was only to the maxilla inserted (Figure 2d). Noinanaesthesia the mouth during was bottle during required feedingthisandprocedure. did not require fixation. The The prosthesis was puppies tolerated only inserted themouth in the prosthesis duringwell and bottle showed and feeding rapiddidandnotnormal requiremilk intake.The fixation. Although puppies small amounts tolerated theofprosthesis nasal discharge well andwere occasionally showed rapid observed and normal after milk drinking, intake. sneezing Althoughand coughing small amounts were neverdischarge of nasal observed,were and there were noobserved occasionally signs of aspiration. after drinking,After 2 weeks, sneezing anda coughing new prosthesis had toobserved, were never be customised, and thereas described were no signsabove, because of of aspiration. physiological After 2 weeks, growth of the puppy. a new prosthesis had toAtbe6 customised, weeks of age, as the ownersabove, described beganbecause mixing of thephysiological puppy milk (Babydog growth Milk® of the , Royal puppy. At Canin, 6 weeksKöln, Germany) of age, the owners withbegan wet dog mixingfoodthe(Starter puppyMousse® , Royal Milk milk (Babydog Canin, ®, Köln, Germany), Royal Canin, Köln, and at 2.5 months Germany) withofwetage, dogthey changed food theMousse (Starter ® feed to commercial , Royal Canin, dry Köln, dog food (Puppy Germany), Large and Breed® at 2.5 months, Eukanuba, of age, they Coevorden, changed the Netherlands), which the feed to commercial dry puppies dog foodcould(Puppy eatLarge without Breedthe ®, prosthesis.Coevorden, Eukanuba, The puppies showed no difficulty Netherlands), which theinpuppies drinking water. could eat without the prosthesis. The puppies showed no difficulty in drinking water. Figure 2.2. A Figure A small small portion portion ofof the the Wilson Wilson Single Single Density Density Youth Youth Mouthguard Mouthguard (Wilson (Wilson Single Single Density Density Youth YouthMouthguard, Mouthguard, Wilson, Wilson,Chicago, Chicago, IL, IL,USA) USA) isis cut cutoff off(a). (a). A A plate plate matching matching the the size size of of the the upper upper jaw is crafted by repeated heating, softening, and reforming the thermoplastic silicone jaw is crafted by repeated heating, softening, and reforming the thermoplastic silicone (b). The warm (b). The warm silicone silicone plate plate is is pressed pressed against against the the upper upper jawjawofofthethepuppy puppy(c).(c). The Thecustomised customised temporary temporary palatal palatal prosthesis prosthesisprepared preparedfor forpuppies puppies with with cleft cleft palate palate from from the the Wilson Wilson Single Single Density Density Youth Youth Mouthguard Mouthguard for for human human children children(d). (d). 2.3. Further Therapies All puppies were treated with frequent inhalation of ambroxol during the first 2 weeks (Mucosolvan® , 6 mg per inhalation, Boehringer Ingelheim, Ingelheim am Rhein) to clear the upper respiratory tract. The puppy in Case 3 received amoxicillin–clavulanic acid for 10 days (Synulox® , 12.5 mg/kg body weight, orally, twice a day, Zoetis, Berlin, Germany) for the management of bronchopneumonia.
Vet. Sci. 2018, 5, 61 4 of 7 2.3. Further Therapies All puppies were treated with frequent inhalation of ambroxol during the first 2 weeks (Mucosolvan® , 6 mg per inhalation, Boehringer Ingelheim, Ingelheim am Rhein) to clear the upper respiratory tract. The puppy in Case 3 received amoxicillin–clavulanic acid for 10 days Vet. Sci. 2018, 5, 61 4 of 7 (Synulox® , 12.5 mg/kg body weight, orally, twice a day, Zoetis, Berlin, Germany) for the management of bronchopneumonia. 2.4. Development 2.4. Development The puppy in Case 1 was raised by one of the authors in isolation from its littermates, while the otherThe twopuppy puppies in were Case raised 1 was along raisedwith by onetheir oflittermates the authorsbyintheir respective isolation from owners. Both ofwhile its littermates, them the other two puppies were raised along with their littermates by their respective owners. BothAll suckled from their mothers without the prosthesis; however, there was no effective milk intake. of puppies were fed by bottle with the prosthesis in place. The puppy in Case 2 showed them suckled from their mothers without the prosthesis; however, there was no effective milk intake. signs of pneumonia at approximately 6 weeks of age, but recovered and developed well after All puppies were fed by bottle with the prosthesis in place. The puppy in Case 2 showed signs of the treatment with amoxicillin–clavulanic pneumonia at approximatelyacid (Synulox® 6 weeks of age,, but 12.5recovered mg/kg bodyandweight, developedorally, welltwice after athe day, Zoetis, treatment Berlin, Germany). Although the puppies ®showed good food intake, the two Boxer puppies with amoxicillin–clavulanic acid (Synulox , 12.5 mg/kg body weight, orally, twice a day, Zoetis, Berlin, exhibited slower body Germany). weight gain Although than their the puppies littermates, showed while good food the Collie intake, the twodeveloped at the exhibited Boxer puppies same rateslower as his littermates. body weight gain than their littermates, while the Collie developed at the same rate as his littermates. 2.5. Outcomes 2.5. Outcomes and and Follow-up Follow-up Between 5–6 Between 5–6 months months ofofage,age,allall three threepuppies puppies(Figure 3) underwent (Figure 3) underwent corrective surgery. corrective Pre- surgery. operatively, a complete blood count and a blood chemistry test were performed Pre-operatively, a complete blood count and a blood chemistry test were performed on all dogs. on all dogs. All values All were values within were withinnormal normal range. range.ForForcorrective correctivesurgery, surgery,thethe medially double-flap medially repositioned double-flap technique (von technique (von Langenbeck Langenbeck technique) was used for the the hard hard palate palate [8][8] and and the the double-layer double-layer appositional technique appositional technique was usedused forfor the the soft soft palate. palate. The The surgical surgical wounds wounds healed healed well, well, with with normal normal symmetry between symmetry between thethe right right and and left left sides sides of of the the maxilla maxilla (Figure (Figure 4). 4). The The puppy puppy in in Case Case 11 developed developed mandibular mandibular mesioclusion after surgery. The cleft lip wound in the puppy in surgery. The cleft lip wound the puppy in Case 2 opened upCase 2 opened up after after surgery, but surgery, but the the owner owner decided decided against against further further corrective corrective surgery surgery because because there there was was no no functional functional constraint. All puppies achieved the same body size and weight constraint. weight as as their their littermates. littermates. At the time time of of writing this article, the dogs were aged 2–4 years. All dogs were healthy and writing this article, the dogs were aged 2–4 years. All dogs were healthy and showed no problems showed no problems associated with associated with their their congenital congenitaldefects defects(Figure (Figure5). 5).The Thecleft liplip cleft persisted persistedin the puppy in the puppyin Case 2, but in Case 2, thisthis but represents a cosmetic represents defect a cosmetic only. defect only. Figure 3. Cleft Figure 3. Cleft palate/cleft lip and palate/cleft lip and palate palate on on the the day day of of corrective corrective surgery surgery in in Case Case 11 (a), (a), Case Case 22 (b) (b) and and Case 3 (c). Case 3 (c).
Vet. Sci. 2018, 5, 61 5 of 7 Vet. Sci. 2018, 5, 61 5 of 7 Vet. Sci. 2018, 5, 61 5 of 7 Figure Figure Figure4.4. Intraoral 4. Intraoral images Intraoral images of images of Case Case 222 (a) of Case (a) and (a) and Case Case 333 (b) and Case (b) (b) 333 days days after days after surgery, after surgery, and surgery,and Case Case111(c) andCase (c) (c)222months months months after after surgery. aftersurgery. Cases surgery.Cases 2 and Cases22and 3 did and33did not didnot require notrequire any requireany further anyfurther surgery. furthersurgery. Case surgery.Case 1 still Case11still showed stillshowed some showedsome fistulas fistulas222 somefistulas months months after monthsafter surgery, aftersurgery, which surgery,which were whichwere successfully weresuccessfully closed. successfullyclosed. closed. Figure Figure5.5. Figure Intraoral 5.Intraoral images Intraoralimages of imagesof Case Case111(a) ofCase (a) (a)444years years and years and Case Case 222 (b) and Case (b) and and Case Case 33 (c) (c) 22 years yearsafter years aftersurgery. after surgery. surgery. 3. Discussion 3. Discussion 3. Discussion Although Although CP Although CP CP isis one isone oneofof the ofthe most themost common mostcommon congenital commoncongenital craniofacial congenitalcraniofacial defects craniofacial defects defects inin dogs, indogs, dogs,mostmost puppies mostpuppies puppies are euthanised are euthanised are euthanised or or die ordie because diebecause becauseof of aspiration ofaspiration pneumonia. aspirationpneumonia. Corrective pneumonia. Corrective surgery Corrective surgery surgery cancan can be be performed be performed performed at at an at an an age of age of age about of about 4–6 about 4–6 months 4–6 months months [5].[5]. Until [5]. Until the Until the puppy the puppy is old enough puppy is old enough for surgery, enough for surgery, nutrition surgery, nutrition nutrition has has to has to be to be ensured, be ensured, ensured, and andthe and the risk therisk risk of of aspiration aspiration of aspiration pneumonia pneumonia pneumonia has tohas has to to bebe minimised. be minimised. minimised. In In children, In children, a feedingaaobturator children, feeding feeding isobturator obturator commonly is is commonly commonly provided provided until until corrective corrective surgery surgery is is performed performed [9,10]. [9,10]. The The preparation preparation provided until corrective surgery is performed [9,10]. The preparation of prosthodontic obturators after of of prosthodontic prosthodontic obturators corrective after after corrective obturatorssurgery corrective surgery surgery for congenital as for wellcongenital for congenital as acquired as well as cleft as as acquired well palates acquired cleft palates cleftand in dogs palates in in dogs cats has beenand dogs and cats cats has has previously been previously been previously described [2,11,12].described described [2,11,12]. [2,11,12]. Martinez-Sanz Martinez-Sanz Martinez-Sanz et al. [4] described et et al. [4] described theal.preparation [4] described the preparation the preparation of customised of feeding customised of customised teats using afeeding feeding teats teats using using aa thermovacuum-forming thermovacuum-forming thermovacuum-forming machine under anaesthesia machine machine under under for the anaesthesia anaesthesia management andfor the the management forraising management of puppies with and and raising raising of puppies of surgery. with puppies Although CP before with CP before surgery. Although surgery. Although they they described described an effective way to raise puppies CP before they described an effective way to raise an effective puppies with wayCP,tothe raise puppies procedure with with for CP, CP, the the procedure manufacturing procedure for manufacturing forand the teats manufacturing the the teats palatal prosthesis teats and and palatal is complex and prosthesis palatal prosthesis is is complex requires special complex and and requires equipment requires as well special special equipment as well as anaesthesia. In the cases presented here, the preparation procedure for equipment as well as anaesthesia. In the cases presented here, the preparation procedure for the the palatal palatal prosthesis prosthesis was was inexpensive, inexpensive, simple, simple, andand effective; effective; moreover, moreover, no no anaesthesia anaesthesia was was needed, needed, all all of of which which areare important important factors factors in in the the willingness willingness of of owners owners to to raise raise aa puppy puppy withwith CP. CP. Although Although aa
Vet. Sci. 2018, 5, 61 6 of 7 as anaesthesia. In the cases presented here, the preparation procedure for the palatal prosthesis was inexpensive, simple, and effective; moreover, no anaesthesia was needed, all of which are important factors in the willingness of owners to raise a puppy with CP. Although a palatal prosthesis needs to be prepared several times as the puppy grows, only one mouthguard (Wilson Single Density Youth Mouthguard) could supply all the material necessary for all the prostheses. Furthermore, the owners could replicate the manufacturing procedure after observing it once, although regular supervision by a veterinarian is recommended. This approach allows the puppy to grow up in a normal social environment. This approach also makes bottle feeding and suckling possible (which are important for normal craniofacial growth [13]) with minimal risk of milk aspiration and subsequent pneumonia. This prosthesis allows for the normal raising of such puppies until most of the maxillofacial growth is complete, preventing maxillofacial deformities and inhibiting maxillary growth that can occur because of palatoplastics [8,14,15]. Although the puppy in Case 1 developed mandibular mesioclusion after surgery, this can be attributed to the breed and was not considered a consequence of the surgery. The optimal time and technique for surgery should be chosen according to the size of the cleft palate [7,16–19]. Although there are various reasons for the development of congenital palatoschisis, there is a genetic predisposition [20–22], and castration of the animal is strongly advised. 4. Conclusions In summary, we described the successful management of puppies with CP using a temporary customised prosthesis, which allowed them to be bottle-fed and successfully raised until corrective surgery could be performed. The findings from this report show that a puppy with CP can be raised with little effort and at low cost, thus encouraging owners to seek appropriate treatment for such puppies instead of considering euthanasia. Author Contributions: T.C. conceived the idea for manufacturing the prosthesis, customised it for the three puppies, and raised the puppy in Case 1; I.R. performed the corrective surgery for all puppies and contributed with her broad knowledge of stomatology; and R.H. and A.W. supported and financed the project. All authors have reviewed the article and approved it for final submission. Funding: This research received no external funding. Acknowledgments: We thank Daniela Graulich for the help with all the cleft palate puppies. Conflicts of Interest: The authors declare no conflicts of interest. References 1. Hoskins, J.D. The Respiratory System. In Veterinary Pediatrics. Dogs and Cats from Birth to Six Months, 2nd ed.; Hoskins, J.D., Ed.; W.B. Saunders: Philadelphia, PA, USA, 1995; p. 73, ISBN 0721638872. 2. Lee, J.I.; Kim, Y.S.; Kim, M.J.; Lee, J.; Choi, J.H.; Yeom, D.B.; Park, J.M.; Hong, S.H. Application of a temporary palatal prosthesis in a puppy suffering from cleft palate. J. Vet. Sci. 2006, 7, 93–95. [CrossRef] [PubMed] 3. Hedlund, C.S. Surgery of the oral cavity and oropharynx. In Small Animal Surgery, 2nd ed.; Fossum, T.W., Ed.; Mosby: St. Louis, MO, USA, 2002; pp. 274–306, ISBN 9781560535799. 4. Martinez-Sanz, E.; Casado-Gomez, I.; Martin, C.; López-Gordillo, Y.; González, P.; Rodríguez-Bobada, C.; Paradas, I.; González-Meli, B.; Maldonado, E.; Maestro, C.; et al. A new technique for feeding dogs with a congenital cleft palate for surgical research. Lab. Anim. 2011, 45, 70–80. [CrossRef] [PubMed] 5. Fiani, N.; Verstraete, F.J.; Arzi, B. Reconstruction of congenital nose, cleft primary palate, and lip disorders. Vet. Clin. North Am. Small Anim. Pract. 2016, 46, 663–675. [CrossRef] [PubMed] 6. Tolwani, R.; Hagan, C.; Runstadler, J.; Lyons, H.; Green, S.; Bouley, D.; Rodriguez, L.; Schendel, S.; Moseley, M.; Daunt, D.; et al. Magnetic resonance imaging and surgical repair of cleft palate in a four-week-old canine (Canis familiaris): An animal model for cleft palate repair. Contemp. Top. Lab. Anim. Sci. 2004, 43, 17–21. [PubMed] 7. Peralta, S.; Fiani, N.; Kan-Rohrer, K.H.; Verstaete, F.J. Morphological evaluation of clefts of the lip, palate, or both in dog. Am. J. Vet. Res. 2017, 78, 926–933. [CrossRef] [PubMed]
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